Giving Birth Too Young: Vesico Vaginal Fistula ‘The Hospital By The River’

 Updated 28 April 2015


The Hospital By The River 

Is written by Australian, Dr Catherine Hamlin about her work in Ethiopia treating women with vaginal fistula.

She and her husband, Dr Reg Hamlin,  also established a school for training midwives in Ethiopia. This is a wonderful book 

which documents the outstanding work by this remarkable couple. Child marriages are common in Ethiopia. However, while reading the book,  I couldn’t help but see the irony in this largely Christian country where priests believe child marriages prevent females living immoral lives like those “women of thirty in Western countries”. The Hamlins continue to carry out surgery on these unfortunate girls and women with obstetric fistulae , while Christian Churches continue to support the culture of child marriages.  Wouldn’t it save so much suffering if educational programmes were taken out to villages and child marriages were outlawed?


The Hospital By The River


Obstetric fistula (or vaginal fistula) is a severe medical condition in which a fistula (hole) develops between either the rectum and vagina or between the bladder and vagina after severe or failed childbirth, when adequate medical care is not available.


Fistula was virtually eradicated in developed countries in the 19th century, following the discovery of caesarean section.


Image: Fistula Foundation


Description of Vesico Vaginal Fistula (VVF), by Hajara Leman (NEXT):
A medical condition peculiar to females, poses a serious health and social challenge to African nations. Medical experts, health analysts and rights activists share the view that the problem is largely avoidable if certain cultural and traditional approaches to issues of marriage and sex are critically reappraised. Experts mostly associate VVF to early marriage of girls who, given their physiological development at such a point in time, can hardly cope with the carriage of pregnancies. It has been noted that childbirth complications such as obstructed labour, as well as adolescent rape, are common causes of VVF conditions.
According to medical experts, obstructed labour occurs when the unborn child is pressed tightly in the birth canal thereby cutting off the flow of blood. Such a situation leads to the death of tissues surrounding the canal, which eventually degenerates to create a hole through which urine then leaks.


Image: Fistula Foundation


Here is a personal story from Farhiya Mohamed Farah, a 20-year-old Somalian refugee, which highlights the pain, suffering and social stigma vaginal fistula causes.

Source: The Gazette Montreal.

Obstetric fistula causes incontinence and affects more than 2 million women around the world, mostly in Africa, according to World Health Organisation estimates. Fistula disproportionately affects child brides whose bodies are not yet ready for childbirth. In Farhiya Mohamed Farah’s case, the condition made her a social outcast for years and caused her husband to divorce her. It was only after she fled from the violence in Mogadishu, to Kenya, that she was able to receive free surgery to treat the problem.

“Nobody wants a woman who passes stools all the time and smells,” whispered Ms Farah, explaining why her husband divorced her when she was pregnant with their second child.

“People would ask ‘who is making that bad smell’, coughing and covering their noses. So I was always isolating myself,” she said. Too poor to buy sanitary pads, she stuffed her underwear with rags. But faeces still leaked onto her clothes, forcing her to wash them several times a day. She doused herself in perfume to hide the smell. A midwife tried to suture the hole four times, without success.

“I was thinking that the rest of my life would be like this until I died,” said Farah, now 20, her birdlike frame shrouded in a red headscarf and skirt. Farah found relief in June at Kenyatta National Hospital’s 15-day ‘fistula camp’, where 102 patients from all over Kenya had surgery for free.

Khisia Wakasiaka, the head surgeon, said that the operation effected an unparalleled transformation in which the women could  “move away from total neglect to somebody with some hope in life”.


A survey of nine African countries by the UN Population Fund (UNFPA) in 2003 found that most fistula patients were poor, uneducated teenagers, who developed a fistula while giving birth to their first child. Some were as young as 12.

When a mother’s hips are too small for the baby’s head to pass through, it presses down on her pelvic bone, cutting off blood supply and causing the tissue to die. The resulting hole causes urinal or faecal incontinence, and the baby usually dies. Complete pelvic bone growth is around 21 years of age; if bones are not completely mature obstructed labour is a risk. Girls aged 15-19 are twice as likely to die in pregnancy or childbirth than women aged 20-24, according to the United Nations.

“Pregnancy at an early age is a huge risk factor for obstructed labour, as a girl’s body has not fully matured and the pelvis is small,” said Kate de Rivero of the Women and Health Alliance, a charity working to improve maternal health. Women can also have a narrow pelvis due to malnutrition in childhood.


Image: Fistula Foundation




Apart from the biological risks, girls who marry at a young age do not have the power to make decisions about their own bodies, including on how and where to give birth. “Decisions on when and where women can give birth are made either by their husbands or by their mothers-in-law,” said Agnes Odhiambo, a women’s rights researcher with Human Rights Watch. “Rarely do those poor, uneducated rural women have a voice to stand up and say: ‘No, I want to go to hospital.”‘

Older women usually prefer to invite traditional birth attendants (TBAs) to the house rather than travel a long distance to the nearest health facility. In Niger, where 15 is the average age of marriage, 85 per cent of women deliver at home, according to UNFPA. “[Birthing women] are kept by the TBA for two, three days,” said Odhiambo. “By the time your mother, your auntie or your grandmother decides to take you to hospital, it is too late. The baby’s dead and [the mother] gets a fistula.”


About 70 per cent of women living with fistula never seek treatment because they don’t know what is wrong with them. “There are all these myths that go on in the communities: you are promiscuous, you are bewitched or you have HIV,” said Odhiambo. “Because it’s stigmatised, [the women] are really ashamed to speak up about it.”

Wakasiaka is working to promote treatment immediately after delivery. If a nurse inserts a catheter, gets the woman to rest and to drink water, 25 per cent of cases heal spontaneously. Community midwives who educate people in the villages have proven effective in reducing maternal death rates.

“If you are able to monitor these women closely in labour and intervene when it’s required, then the risk of fistula formation is reduced markedly,” Wakasiaka said.


-Anne Frandi-Coory 23 August 2011

My book review for The Hospital By The River  by Australian, Doctor Catherine Hamlin


FISTULA FOUNDATION  website is well worth a visit


See more about the work in this field, carried out for over 50 years by Australian, Dr Catherine Hamlin, in Ethiopia


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